ORIGINAL RESEARCH published: 26 January 2021 doi: 10.3389/fpubh.2020.588578

Depressive Symptoms, Sleep Quality and Diet During the 2019 Novel Coronavirus Epidemic in China: A Survey of Medical Students

Jianping Xie 1,2,3†, Xia Li 1†, Haiyun Luo 1†, Liu He 1, Yufan Bai 1, Fuyun Zheng 1, Lanchun Zhang 2, Jiaqing Ma 1, Zhiqiang Niu 1, Yubing Qin 1, Ling Wang 1, Wenjie Ma 1, Haofei Yu 2, Rongping Zhang 2,4* and Ying Guo 1*

1 School of Basic Medical Sciences, Medical University, Kunming, China, 2 School of Pharmaceutical Science, Department of Zoology & Key Laboratory of Pharmacology for Natural Products, Kunming Medical University, Kunming, China, 3 Department of Technology, Library, , Kunming, China, 4 School of Chinese Materia Medica and Yunnan Key Laboratory of Southern Medicinal Resources, of Chinese Medicine, Kunming, Edited by: China Wulf Rössler, Charité—Universitätsmedizin The psychological condition of medical students may be influenced by the 2019 novel Berlin, Germany coronavirus (COVID-19) outbreak. This study investigated the prevalence and influencing Reviewed by: Yaoguang Zhou, factors of depressive symptoms, poor sleep quality and poor diet in students at Kunming Second Military Medical Medical University during the early part of the COVID-19 outbreak. A cross-sectional University, China Cyrus S. H. Ho, study was used from a questionnaire survey in February 2020. Of a total of 1,026 study National University Health participants, the prevalence of depressive symptoms, poor sleep quality, and poor diet System, Singapore was, respectively, 22.4, 33.2, and 17.4%. Male students and students with a low degree *Correspondence: of focus on COVID-19 had a high risk of depressive symptoms. A high percentage of Ying Guo [email protected] females and students in the fifth grade, as well as students with high levels of concern Rongping Zhang about the negative impact of COVID-19 on their education or employment, comprised [email protected] those with poor sleep quality. Students in the fifth grade and students with high levels †These authors have contributed of concern about the negative impact of COVID-19 on their education or employment equally to this work were more likely to report poor diet. This study suggests the importance of monitoring

Specialty section: medical students’ depressive state during the COVID-19 outbreak, and universities are This article was submitted to encouraged to institute policies and programs to provide educational counseling and Public Mental Health, a section of the journal psychological support to help students to cope with these problems. Frontiers in Public Health Keywords: academic stress, employment pressure, COVID-19, medical students, depression Received: 29 July 2020 Accepted: 31 December 2020 Published: 26 January 2021 INTRODUCTION Citation: Xie J, Li X, Luo H, He L, Bai Y, According to epidemiological data published in Nature, the prevalence of depression in China Zheng F, Zhang L, Ma J, Niu Z, Qin Y, was reported to be 3.02% (1). The lifetime prevalence of depressive disorders was 6.9%, while Wang L, Ma W, Yu H, Zhang R and the 12-months prevalence of depressive disorders was 3.6% (2). The prevalence of depressive Guo Y (2021) Depressive Symptoms, disorder was 8.8% of the study population among college students in China (3). The prevalence Sleep Quality and Diet During the 2019 Novel Coronavirus Epidemic in of depression among medical students in China has been reported with a mean of 32.74%, China: A Survey of Medical Students. based on a published meta-analysis (4). In America, the prevalence rates of depression in college Front. Public Health 8:588578. students ranged from 7 to 9% (5), while the prevalence of 6.0–66.5% for depression in medical doi: 10.3389/fpubh.2020.588578 students was recorded (6). Additionally, the number of students at universities who suffered

Frontiers in Public Health | www.frontiersin.org 1 January 2021 | Volume 8 | Article 588578 Xie et al. A Survey of Medical Students from mental problems was increasing (7). Since December grade students, 225 (21.9%) third grade students, 229 (22.3%) 2019, cases of pneumonia have appeared in Wuhan city, fourth grade students, and 146 (14.2%) fifth grade students. Hubei Province, China (8, 9). This kind of pneumonia is a highly contagious disease caused by the 2019 novel coronavirus Data Collection (COVID-19), which is characterized by a rapid transmission. This study was conducted during the early outbreak of Among those who developed symptoms, about 15% became COVID-19 in February 2020, and data were collected from seriously ill and 5% became critically ill. Complications leading to February 18 to February 22 through online questionnaires. death may include respiratory failure, acute respiratory distress The questionnaire included three parts: basic information, syndrome, sepsis and septic shock, thromboembolism, and COVID-19-related information, and assessment of depressive multiorgan failure1. The impact of COVID-19 in China was state, sleep quality and diet. The final study population even greater than that of severe acute respiratory syndrome consisted of a total of 1,026 undergraduate students majoring in (SARS) in 2002. One study suggested that the SARS outbreak clinical medicine. showed a psychosocial influence on Chinese students, even though none of them became infected SARS (10). Depression Measurements accompanied major sleep problems in post-SARS syndrome was Basic Information reported (11). Insomnia was both a frequent symptom and a risk Demographic variables included gender (male or female), grade factor of depression (12). The positive relationships between a group (first grade, second grade, third grade, fourth grade, or fifth well-diet and sleep state and improved human health was also grade), age group (16–18, 19–21, 22–24, or 25–26 years), and documented (13). According to this evidence, we presume that location (five named provinces or other). Because more clinical the psychological condition, the sleep quality and the diet state of medicine students at Kunming Medical University were females medical students may be influenced by the COVID-19 outbreak. than males, more females than males were enrolled in the study. Although there have been many empirical studies about Because more students were from Yunnan Province, the number depression in medical students in China, few studies to date of students from five provinces, including Hubei, Guangdong, have conducted a survey on the depressive symptoms, the sleep Henan, Zhejiang and Hunan provinces, was significantly lower quality and the diet state of medical students at Kunming than the number of students from other provinces in China. The Medical University during the COVID-19 pneumonia outbreak. selection of these five provinces was based on the cumulative Therefore, the purpose of this study is to perform a cross- confirmed number of novel coronavirus pneumonia cases >1,000 sectional study of the prevalence and influencing factors of on February 22, 2020. depressive symptoms, sleep quality and diet during the early COVID-19 outbreak and to lay the groundwork for further Depressive Symptoms measures for at-risk medical students. The modified Chinese version of the Self-Rated Depression scale was used to evaluate the outcomes of depressive symptoms over the past 2 weeks. The scale was composed of 20 METHODS multiple choice questions. The total score ranged from 0 to Study Design and Participants 60, and a total score of >22 was defined as indicative of The study was designed to investigate the subjects’ depressive depressive symptoms. symptoms, sleep quality and diet. To select a representative Sleep Quality sample of respondents, we distributed an invitation to We used the modified Chinese version of the Pittsburgh Sleep clinical medical undergraduates to complete the web-based Quality Index scale to measure students’ sleep quality over the questionnaire. This web-based questionnaire was sent to the past 2 weeks. The total score ranged from 0 to 21, and a score >7 WeChat public platform. All invited students may see this was defined as indicative of poor sleep quality. questionnaire and may answer it by scanning the quick response code. This web-based survey was non-commercial, anonymous, State of Diet and completely voluntary. This was a cross-sectional design. The modified Chinese versionof the state of diet scale was applied We adopted a stratified sampling method to recruit the clinical to assess the students’ diet. The scale contained items on loss medical undergraduates of the University from students in of appetite, overeating, constipation, etc. The total score ranged the first, second, third, fourth and fifth grade. Non-clinical from0to15,andascore >5 was defined as indicative of poor diet. majors within the same university such as nursing and medical imaging were excluded. Students who met with the criteria Degree of Focusing on the COVID-19 or Concerned were all invited to complete the questionnaire. The estimated About Negative Impact of COVID-19 on Education or sample sizes required for the first, second, third, fourth and fifth Employment grade were respectively 167, 160, 164, 163, and 161. In total, A series of questions related to emotions were applied to assess 1026 respondents completed the questionnaire. The final sample the degree of focusing on the COVID-19 or concerned about composed of 244 (23.8%) first grade students, 182 (17.7%) second negative impact of COVID-19 on education or employment. The total score ranged from 0 to 20, and a score >6 was defined 1www.who.int/emergencies/diseases/novel-coronavirus-2019 as indicative of high degree of focusing on the COVID-19 or

Frontiers in Public Health | www.frontiersin.org 2 January 2021 | Volume 8 | Article 588578 Xie et al. A Survey of Medical Students

TABLE 1 | Demographic characteristics of study sample (N = 1,026). concerned about the negative impact of COVID-19 on their education or employment. Variable n (%)

GENDER Prevalence of Depressive Symptoms, Male 373 (36.4%) Sleep Quality, and Diet During the Female 653 (63.6%) COVID-19 Outbreak in Medical Students, GRADE Stratified by Gender, Grade, Age, and First 244 (23.8%) Second 182 (17.7%) Location Tables 2 5 Third 225 (21.9%) – presents the prevalence of depressive symptoms, poor Fourth 229 (22.3%) sleep quality, and poor diet during the COVID-19 outbreak Fifth 146 (14.2%) in medical students, who were stratified by gender, grade, AGE age, and location. The prevalence of depressive symptoms was < Table 2 16–18 87 (8.5%) significantly higher in males than in females (P 0.05, ), while the prevalence of poor sleep quality was significantly higher 19–21 519 (50.6%) in females than in males (P < 0.05, Table 2). Compared with 22–24 406 (39.6%) students in other grades, students in the fifth grade reported 25–26 14 (1.4%) the highest rate of poor sleep quality and poor diet (P < 0.05, LOCATION Table 3). There was no significant difference in the prevalence of Five provinces 19 (1.9%) depressive symptoms, poor sleep quality, or poor diet by age (P Other provinces 1,007 (98.1%) > 0.05, Table 4) or by location (P > 0.05, Table 5). DEGREE OF FOCUSING ON THE COVID-19 High 710 (69.2%) Low 316 (30.8%) Association of Influencing Factors With DEGREE OF CONCERNED ABOUT NEGATIVE IMPACT OF COVID-19 ON Depressive Symptoms, Poor Sleep Quality, EDUCATION OR EMPLOYMENT and Poor Diet During the COVID-19 High 608 (59.3%) Outbreak Low 418 (40.7%) Table 6 presents the association of influencing factors of

Total 1,026 (100%) depressive symptoms, poor sleep quality, and poor diet during the COVID-19 outbreak. In the univariate logistic regression models, gender (OR = 1.45, 95% CI: 1.07–1.96) and degree of focus on COVID-19 (OR = 1.47, 95% CI: 1.08–2.00) were concerned about negative impact of COVID-19 on education significantly associated with depressive symptoms. Gender (OR = = or employment. 0.72, 95% CI: 0.55–0.95), grade (OR 2.68, 95% CI: 1.72– 4.18) and degree of concern about the negative impact of COVID-19 on education or employment (OR = 2.10, 95% Statistical Analysis CI: 1.59–2.77) were related to poor sleep quality during the χ 2 The data were analyzed using chi-square tests ( ) to compare COVID-19 outbreak in medical students. Similarly, grade (OR the differences between groups and univariate and multivariate = 2.91, 95% CI: 1.70–4.98) and degree of concern about the logistic regression models to seek potential influencing factors for negative impact of COVID-19 on education or employment depressive symptoms, sleep quality and diet during the COVID- (OR = 1.60, 95% CI: 1.13–2.25) were associated with poor 19 outbreak. P-values were two-sided and considered significant diet, but gender was not associated with poor diet (OR = 0.76, < at P 0.05. All analyses were conducted using SPSS 19.0 (SPSS 95% CI: 0.54–1.08). Inc., Chicago, IL, USA). The associations weakened, but there were still significant differences in the multivariate logistic regression models. Male RESULTS students (AOR = 1.42, 95% CI: 1.05–1.93) and students focusing less on COVID-19 (AOR = 1.47, 95% CI: 1.07–2.02) had a Demographic Characteristics higher risk of depressive symptoms than did female students and Table 1 presents the general characteristics of the study students highly focused on COVID-19, respectively. Compared population. Of a total of 1,026 study participants, 373 (36.4%) with females, males were less likely to have poor sleep quality were males and 653 (63.6%) were females. Among these (AOR = 0.74, 95% CI: 0.56–0.98). Students in the fifth grade participants, 244 (23.8%) students were in the first grade, 519 (AOR = 2.26, 95% CI: 1.19–4.29) and students with high (50.6%) students were 19–21 years of age, and 1,007 (98.1%) concerns about the negative impact of COVID-19 on their students were located in provinces other than the five provinces education or employment (AOR = 2.12, 95% CI: 1.55−2.88) of interest (Hubei, Guangdong, Henan, Zhejiang, and Hunan were more likely to have poor sleep quality than were students provinces). A total of 710 (69.2%) students were highly focused in other grades and students without concerns about the negative on COVID-19. A total of 608 (59.3%) students were highly impact of COVID-19 on education or employment, respectively.

Frontiers in Public Health | www.frontiersin.org 3 January 2021 | Volume 8 | Article 588578 Xie et al. A Survey of Medical Students

TABLE 2 | Prevalence of depressive symptoms, sleep quality, and state of diet during COVID-19 outbreak in medical students stratified by gender (N = 1,026).

Variables Male Female Total χ 2 P-value (N = 373) (N = 653) (N = 1,026)

n (%) n (%) n (%)

Depressive symptoms 5.73 0.017 No 274(73.5%) 522(79.9%) 796(77.6%) Yes 99(26.5%) 131(20.1%) 230(22.4%) Sleep quality 5.47 0.019 Good 266(71.3%) 419(64.2%) 685(66.8%) Poor 107(28.7%) 234(35.8%) 341(33.2%) State of diet 2.41 0.121 Good 317(85.0%) 530(81.2%) 847(82.6%) Poor 56(15.0%) 123(18.8%) 179(17.4%)

TABLE 3 | Prevalence of depressive symptoms, sleep quality, and state of diet during COVID-19 outbreak in medical students stratified by grade (N = 1,026).

Variables First Second Third Fourth Fifth Total χ 2 P-value (N = 244) (N = 182) (N = 225) (N = 229) (N = 146) (N = 1026)

n (%) n (%) n (%) n (%) n (%) n (%)

Depressive symptoms 4.32 0.364 No 194(79.5%) 140(76.9%) 171(76.0%) 185(80.8%) 106(72.6%) 796(77.6%) Yes 50(20.5%) 42(23.1%) 54(24.0%) 44(19.2%) 40(27.4%) 230 (22.4%) Sleep quality 21.27 <0.001 Good 189(77.5%) 116(63.7%) 145(64.4%) 153(66.8%) 82(56.2%) 685(66.8%) Poor 55(22.5%) 66(36.3%) 80(35.6%) 76(33.2%) 64(43.8%) 341 (33.2%) State of diet 20.23 <0.001 Good 216(88.5%) 144(79.1%) 183(81.3%) 198(86.5%) 106(72.6%) 847(82.6%) Poor 28(11.5%) 38(20.9%) 42(18.7%) 31(13.5%) 40(27.4%) 179 (17.4%)

TABLE 4 | Prevalence of depressive symptoms, sleep quality, and state of diet during COVID-19 outbreak in medical students stratified by age (N = 1,026).

Variables 16–18 19–21 22–24 25–26 Total χ 2 P-value (N = 87) (N = 519) (N = 406) (N = 14) (N = 1,026)

n (%) n (%) n (%) n (%) n (%)

Depressive symptoms 0.74 0.864 No 70(80.5%) 402(77.5%) 314(77.3%) 10(71.4%) 796(77.6%) Yes 17(19.5%) 117(22.5%) 92(22.7%) 4(28.6%) 230(22.4%) Sleep quality 6.67 0.083 Good 62(71.3%) 360(69.4%) 256(63.1%) 7(50.0%) 685(66.8%) Poor 25(28.7%) 159(30.6%) 150(36.9%) 7(50.0%) 341(33.2%) State of diet 3.52 0.319 Good 77(88.5%) 428(82.5%) 332(81.8%) 10(71.4%) 847(82.6%) Poor 10(11.5%) 91(17.5%) 74(18.2%) 4(28.6%) 179(17.4%)

In addition, compared with students in other grades and students DISCUSSION without concerns about the negative impact of COVID-19 on education or employment, students in the fifth grade (AOR = Our study showed that the prevalence of depressive symptoms, 2.92, 95% CI: 1.33–6.39) and students with high concerns about poor sleep quality, and poor diet was 22.4, 33.2, and 17.4%, the negative impact of COVID-19 on education or employment respectively. Male students and students with low COVID- (AOR = 1.55, 95% CI: 1.06–2.28) were more likely to report 19 scores had a higher risk of depressive symptoms. Females, poor diet. students in the fifth grade, and students with high concerns

Frontiers in Public Health | www.frontiersin.org 4 January 2021 | Volume 8 | Article 588578 Xie et al. A Survey of Medical Students

TABLE 5 | Prevalence of depressive symptoms, sleep quality, and state of diet during COVID-19 outbreak in medical students stratified by location (N = 1,026).

Variables Other provinces Five provinces Total χ 2 P-value (N = 1,007) (N = 19) (N = 1,026)

n (%) n (%) n (%)

Depressive symptoms 0.02 0.886 No 781(77.6%) 15(78.9%) 796(77.6%) Yes 226(22.4%) 4(21.1%) 230(22.4%) Sleep quality 0.69 0.407 Good 674(66.9%) 11(57.9%) 685(66.8%) Poor 333(33.1%) 8(42.1%) 341(33.2%) State of diet 2 0.158 Good 829(82.3%) 18(94.7%) 847(82.6%) Poor 178(17.7%) 1(5.3%) 179(17.4%)

TABLE 6 | Results of univariate and multivariate logistic regression analyses (N = 1,026).

Variable Depressive symptoms Sleep quality State of diet

OR(95%CI) AOR(95%CI) OR(95%CI) AOR(95%CI) OR(95%CI) AOR(95% CI)

GENDER Male 1.45(1.07,1.96)* 1.42(1.05,1.93)* 0.72(0.55,0.95)* 0.74(0.56,0.98)* 0.76(0.54,1.08) 0.76(0.53,1.08) Female 1.00 1.00 1.00 1.00 1.00 1.00 GRADE First 1.00 1.00 1.00 1.00 1.00 1.00 Second 1.16(0.73,1.85) 1.18(0.71,1.96) 1.96(1.28,2.99)* 2.36(1.45,3.87)* 2.04(1.20,3.47)* 2.05(1.14,3.72)* Third 1.23(0.79,1.90) 1.27(0.76,2.13) 1.90(1.26,2.85)* 2.21(1.34,3.64)* 1.77(1.06,2.97)* 1.85(1.01,3.40)* Fourth 0.92(0.59,1.45) 0.90(0.49,1.66) 1.71(1.14,2.57)* 1.56(0.89,2.73) 1.21(0.70,2.09) 1.21(0.59,2.45) Fifth 1.46(0.91,2.36) 1.45(0.72,2.91) 2.68(1.72,4.18)* 2.26(1.19,4.29)* 2.91(1.70,4.98)* 2.92(1.33,6.39)* AGE 16–18 0.84(0.21,3.47) 0.74(0.18,3.06) 0.40(0.13,1.27) 1.01(0.28,3.67) 0.33(0.09,1.23) 0.81(0.18,3.70) 19–21 0.91(0.26,3.23) 0.82(0.23,2.90) 0.44(0.15,1.28) 0.60(0.19,1.90) 0.53(0.16,1.73) 0.85(0.23,3.08) 22–24 0.85(0.26,2.84) 0.77(0.23,2.56) 0.59(0.20,1.70) 0.61(0.20,1.83) 0.56(0.17,1.83) 0.65(0.19,2.20) 25–26 1.00 1.00 1.00 1.00 1.00 1.00 LOCATION Otherprovinces 1.02(0.33,3.11) 0.96(0.31,2.98) 0.68(0.27,1.71) 0.73(0.28,1.90) 3.87(0.51,29.14) 3.68(0.48,28.13) Five provinces 1.00 1.00 1.00 1.00 1.00 1.00 DEGREE OF FOCUSING ON THE COVID-19 Low 1.47(1.08,2.00)* 1.47(1.07,2.02)* 1.00(0.75,1.32) 0.90(0.67,1.21) 1.13(0.80,1.59) 1.09(0.76,1.57) High 1.00 1.00 1.00 1.00 1.00 1.00 DEGREE OF CONCERNED ABOUT NEGATIVE IMPACT OF COVID-19 ON EDUCATION OR EMPLOYMENT Low 1.00 1.00 1.00 1.00 1.00 1.00 High 1.12(0.83,1.52) 1.05(0.75,1.47) 2.10(1.59,2.77)* 2.12(1.55,2.88)* 1.60(1.13,2.25)* 1.55(1.06,2.28)*

*P < 0.05. about the negative impact of COVID-19 on their education or than that in female students, although previous research has employment were more likely to have poor sleep quality. Students shown that depression was more prevalent in female students in the fifth grade and students with high concerns about the than in male students (14). One possible reason for this finding negative impact of COVID-19 on their education or employment may be males are not good at releasing pressure. It is suggested were more likely to report poor diet. that males take part in outdoor activities appropriately, do sports The questionnaire survey showed that over one-fifth of the regularly, relax their requirements on themselves and establish undergraduates had depressive symptoms. This result is in beneficial interests and hobbies, which can release pressure and accordance with the range reported in a previous study for regulate physical and mental health. Chinese medical students (4). Our survey revealed that the Studies have reported that an increased risk of depressive incidence of depressive symptoms in male students was higher symptoms was associated with poor sleep quality (15). A study

Frontiers in Public Health | www.frontiersin.org 5 January 2021 | Volume 8 | Article 588578 Xie et al. A Survey of Medical Students from China found that 34.3% of middle-school students had fairs to provide more research assistant positions, track the sleep problems (16). Our findings showed that over one-third of employment situation of graduates, and provide recruitment female students had poor sleep, which was significantly higher information to graduates in time to alleviate the negative impact than the corresponding estimate for male students. One possible of COVID-19 on employment. For fifth-year students who are reason for this finding may be the differences between men and preparing to take the postgraduate entrance examination, the women in facing stress (17). Females achieved at significantly state has eased the pressure of admission by expanding the higher level than males, in regard to detaching themselves from enrollment scale and providing online entrance examination. the emotions of a situation (18). Additionally, coping strategies Fortunately, during the epidemic outbreak at our university of women included more frequent social and emotional support in February 2020, all undergraduate students were spending (19). For females, the ruminative coping style was generally their winter vacation at home. The vacation exerted a positive adopted, whereas males used the distractive coping style (20). impact on population health with regard to depressive symptoms Female gender showed the worst condition for sleep quality (29, 30). Additionally, medical students have a thorough and insomnia during the home confinement period in Italian knowledge of the regulation of medicines and the development (21). Therefore, greater chronic stress and psychological distress of diseases, and therefore, they mastered ways to cope with during the COVID-19 outbreak may cause more sleep problems the epidemic situation. After encountering the epidemic, non- for female students than for male students. Healthy sleep lectures medical students possibly think more about how to reduce the are held for female students, and it is suggested that they impact of the epidemic on themselves and their families. More arrange their study plan and rest time reasonably, and carry out medical students think about how to use what they have learned psychological counseling timely. to help others understand COVID-19, how to guide others to We found that grade was a potential risk factor for poor sleep take reasonable precautions to avoid transmission and infection quality and poor diet, and fifth graders had the highest incidence of COVID-19, and how to help people relieve anxiety and tension of poor sleep and poor diet. A study reported that senior during the epidemic. There has been no large-scale outbreak medical students grapple with fatigue caused by unprecedented in Yunnan and the medical system is functioning normally. levels of sleep deprivation (22). One reason for poor sleep and After the outbreak, medical students received more detailed poor diet in fifth-grade students may be greater employment training in epidemiology and clinical skills. Compared to medical or examination pressures they are facing. In turn, poor sleep students in Vietnam (31), medical students at Kunming Medical quality has a negative impact on academic performance (23), University provide support for the covid-19 response by means which aggravates academic stress. Medical students with large of science popularization, auxiliary psychological counseling and employment pressure showed more anxiety symptoms (24). epidemiological data collection. Moreover, in response to the Additionally, a study in Mexico reported that depressed medical outbreak of the epidemic, the university immediately suspended students showed a combination of severe academic stress and classes and used online courses to replace traditional classroom sleep problems (25). Psychosocial stress and abnormal diet teaching. For graduating students, the use of online tools to find (loss of appetite or overeating) are interrelated epidemiological employment instead of finding a job face-to-face has solved the phenomena that are already present in youth (26). Another study practical difficulties of graduates. To relieve the various aspects suggested that the neural mechanism of acute stress affecting of pressure faced by medical students, it is suggested that the appetite was by the frontal pole (27). Direct or indirect stress university build a network psychological counseling room to help from COVID-19 may be the cause of abnormal diet during the students cope with mental health challenges. COVID-19 outbreak. This study has two limitations. First, the duration of this study Meanwhile, the degree of concern about the negative impact was short. However, the objective of this study was to assess the of COVID-19 on education or employment was a potential immediate depressive symptoms, poor sleep quality, and poor risk factor for poor sleep quality and poor diet. Students who diet during the early COVID-19 outbreak. In subsequent studies, felt more academic stress or employment pressure during the we will further track the depressive state of medical students COVID-19 outbreak had poor sleep and a poor diet. It is possible over a longer period of time. Second, the subjects in this study that the severe impact of the novel coronavirus pneumonia were medical students at Kunming Medical University, which is outbreak aggravates the academic stress or employment pressure restricted by the region. The research area should be expanded faced by the students. COVID-19 affects the lower respiratory to include medical students in all medical universities in China. tract and manifests as pneumonia in humans. The breath However, the findings in this study still suggest the importance exhaled by patients with pneumonia carries many viruses, and of monitoring medical students’ mental health during the novel its droplets are very infectious (28). The continuous increase coronavirus epidemic. Measures should be strengthened to in the incidence of novel coronavirus pneumonia has seriously reduce the stress of novel coronavirus pneumonia and other affected the everyday lives of Chinese people, although the factors in medical students. incidence in Yunnan Province is low. The increasing academic or employment stress may also indicate that to stop the spread of COVID-19, the government must take measures of closure, CONCLUSIONS which will delay the students’ return to school and make it difficult for graduates to find jobs. For the fifth grade students In conclusion, our study identified a major mental health burden who are looking for jobs, the university will hold online job of medical students during the COVID-19 outbreak. Male

Frontiers in Public Health | www.frontiersin.org 6 January 2021 | Volume 8 | Article 588578 Xie et al. A Survey of Medical Students students and students with a low degree of focus on COVID- AUTHOR CONTRIBUTIONS 19 had a high risk of depressive symptoms. A high percentage of females and students in the fifth grade, as well as students with JX, XL, HL, RZ, and YG: Conceptualization and formal high levels of concern about the negative impact of COVID-19 analysis. YB, LH, FZ, LZ, and JM: Data curation. HL, on their education or employment, comprised those with poor HY, RZ, and YG: Funding acquisition. ZN, YQ, LW, sleep quality. Students in the fifth grade and students with high WM, and HY: Methodology. JX, XL, and HL: Writing— levels of concern about the negative impact of COVID-19 on original draft. RZ and YG: Writing—review & editing. their education or employment were more likely to report a poor All authors contributed to the article and approved the diet. This study suggests the importance of monitoring medical submitted version. students’ depressive state during the early part of the COVID-19 outbreak, and universities are encouraged to institute policies and FUNDING programs to provide educational counseling and psychological support to help students cope with these problems. This work was supported by Yunnan Scholar of Yunling (YNWR-YLXZ-2019-019), Applied Basic Research Key Project DATA AVAILABILITY STATEMENT of Yunnan (Grant Agreement Nos. 2019FA033 and 2019FA031), Program Innovative Research Team in Science and Technology The raw data supporting the conclusions of this article will be in Yunnan Province (Grant Agreement No. 202005AE160004), made available by the authors, without undue reservation. National Natural Science Foundation of China (Grant Agreement Nos. 82060650 and 31900290), Applied Basic Research Project ETHICS STATEMENT of Yunnan (Grant Agreement No. 202001AT070137), and Teaching Reform Project of Kunming Medical University (Grant The study was approved by the Research Ethics Committees Agreement No. J132100623). of Kunming Medical University, Yunnan Province, China, and conducted in accordance with the Declaration of Helsinki ACKNOWLEDGMENTS principles. Informed consent from all participants was included at the start of the questionnaire, and all participants voluntarily We would like to thank the participants who responded participated or withdrew from the questionnaire. our questionnaires.

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